Exploring perceptions and operational considerations for use of a smartphone application to self-monitor blood pressure in pregnancy in Lombok, Indonesia: protocol for a qualitative study.

INTRODUCTION: Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal deaths globally and require close monitoring of blood pressure (BP) to mitigate potential adverse effects. Despite the recognised need for research on self-monitoring of blood pressure (SMBP) among pregnant populations, there are very few studies focused on low and middle income contexts, which carry the greatest burden of HDPs. The study aims to understand the perceptions, barriers, and operational considerations for using a smartphone software application to perform SMBP by pregnant women in Lombok, Indonesia. METHODS AND ANALYSIS: This study includes a combination of focus group discussions, in-depth interviews and workshop observations. Pregnant women will also be provided with a research version of the smartphone BP application to use in their home and subsequently provide feedback on their experiences. The study will include pregnant women with current or past HDP, their partners and the healthcare workers involved in the provision of antenatal care services within the catchment area of six primary healthcare centres. Data obtained from the interviews and observations will undergo thematic analyses using a combination of both inductive and deductive approaches. ETHICS AND DISSEMINATION: The study was approved by the World Health Organization (WHO) and Human Reproduction Programme (HRP) Research Project Review Panel and WHO Ethical Review Committee (A65932) as well as the Health Research Ethics Committee, Faculty of Medicine, Universitas Mataram in Indonesia (004/UN18/F7/ETIK/2023).Findings will be disseminated through research publications and communicated to the Lombok district health offices. The analyses from this study will also inform the design of a subsequent impact evaluation.

Measuring women's experiences during antenatal care (ANC): scoping review of measurement tools.

BACKGROUND: The new WHO model for antenatal care (ANC) focuses on improving practice, organisation and delivery of ANC within health systems, which includes both clinical care and women's experiences of care. The goal of this review is to identify tools and measures on women's experiences of ANC. METHODS: We conducted a scoping review to identify tools and measures on women's experiences of ANC. An iterative approach was used to review all tools in a series of four steps: (1) identify papers between 2007 and 2023; (2) identify the tools from these papers; (3) map relevant measures to conceptualizations of experiences of care, notably mistreatment of women and respectful maternity care and (4) identify gaps and opportunities to improve measures. RESULTS: Across the 36 tools identified, a total of 591 measures were identified. Of these, 292/591 (49.4%) measures were included and mapped to the typology of mistreatment of women used as a definition for women's experiences care during ANC in this review, while 299/591 (44.9%) irrelevant measures were excluded. Across the included measures, the highest concentration was across the domains of poor rapport between women and providers (49.8%) followed by failure to meet professional standards of care (23.3%). Approximately, 13.9% of measures were around overall respectful care, followed by health systems (6.3%), and any  physical or verbal abuse, stigma and/or discrimination (4.8%) . CONCLUSION: This analysis provides an overview of the existing tools, gaps and opportunities to measure women's experiences during ANC. Expanding beyond the childbirth period, these findings can be used to inform existing and future tools for research and monitoring measuring women's experiences of ANC.

Understanding communication in community engagement for maternal and newborn health programmes in low- and middle-income countries: a realist review.

As community engagement (CE) is implemented for sustainable maternal and newborn health (MNH) programming, it is important to determine how these approaches work. Low- and middle-income countries (LMICs) have become a particular focus for MNH CE activities due to their high burden of maternal and neonatal deaths. MNH messaging and communication to engage communities are likely to differ by context, but how these approaches are actually developed and implemented within CE is not well understood. Understanding how communications in CE actually work is vital in the translation of learnings across programmes and to inform future projects. The purpose of this realist review is to describe how, why, to what extent and for whom communications in CE contribute to MNH programming in LMICs. After searching academic databases, grey literature and literature suggested by the expert advisory committee, documents were included if they described the CE communication processes/activities used for MNH programming in an LMIC. Relevant documents were assessed for richness (depth of insight) and rigor (trustworthiness and coherence of data/theories). Data were extracted as context-mechanism-outcome configurations (CMOCs) and synthesized into demi-regularities to contribute to theory refinement. After screening 416 records, 45 CMOCs were extracted from 11 documents. This informed five programme theories explaining that communications in CE for an MNH programme work when: communities are actively involved throughout the programme, the messaging and programme are acceptable, communication sources are trusted, the community has a reciprocal relationship with the programme and the community sees value in the programme. While these findings reflect what is often anecdotally known in CE or acknowledged in communications theory, they have implications for policy, practice and research by highlighting the importance of centring the community's needs and priorities throughout the stages of developing and implementing communications for CE in MNH.

Experiences in aligning WHO SMART guidelines to classification and terminology standards.

OBJECTIVES: Digital adaptation kits (DAKs) distill WHO guidelines for digital use by representing them as workflows, data dictionaries and decision support tables. This paper aims to highlight key lessons learnt in coding data elements of the antenatal care (ANC) and family planning DAKs to standardised classifications and terminologies (CATs). METHODS: We encoded data elements within the ANC and family planning DAKs to standardised CATs from the WHO CATs and other freely available CATs. RESULTS: The coding process demonstrated approaches to refine the data dictionaries and enhance alignment between data elements and CATs. DISCUSSION: Applying CATs to WHO clinical and public health guidelines can ensure that recommendations are operationalised in a digital system with appropriate consistency and clarity. This requires a multidisciplinary team and careful review to achieve conceptual equivalence between data elements and standardised terminologies. CONCLUSION: The systematic translation of guidelines into digital systems provides an opportunity for leveraging CATs; however, this approach needs further exploration into its implementation in country contexts and transition into machine-readable components.

Comprehensive framework for integrated action on the prevention, diagnosis, and management of anemia: An introduction.

The World Health Organization (WHO) announced in 2021 a commitment to develop a comprehensive framework for integrated action on the prevention, diagnosis, and management of anemia and to establish an Anaemia Action Alliance to support the implementation of the framework. WHO commissioned four background papers to provide reflections about the most pressing issues to be addressed for accelerating reductions in the prevalence of anemia. Here, we provide a complete vision of the framework.

Accuracy of a smartphone application for blood pressure estimation in Bangladesh, South Africa, and Tanzania.

Undetected and unmonitored hypertension carries substantial mortality and morbidity, especially during pregnancy. We assessed the accuracy of OptiBPTM, a smartphone application for estimating blood pressure (BP), across diverse settings. The study was conducted in community settings: Gaibandha, Bangladesh and Ifakara, Tanzania for general populations, and Kalafong Provincial Tertiary Hospital, South Africa for pregnant populations. Based on guidance from the International Organization for Standardization (ISO) 81,060-2:2018 for non-invasive BP devices and global consensus statement, we compared BP measurements taken by two independent trained nurses on a standard auscultatory cuff to the BP measurements taken by a research version of OptiBPTM called CamBP. For ISO criterion 1, the mean error was 0.5 ± 5.8 mm Hg for the systolic blood pressure (SBP) and 0.1 ± 3.9 mmHg for the diastolic blood pressure (DBP) in South Africa; 0.8 ± 7.0 mmHg for the SBP and -0.4 ± 4.0 mmHg for the DBP in Tanzania; 3.3 ± 7.4 mmHg for the SBP and -0.4 ± 4.3 mmHg for the DBP in Bangladesh. For ISO criterion 2, the average standard deviation of the mean error per subject was 4.9 mmHg for the SBP and 3.4 mmHg for the DBP in South Africa; 6.3 mmHg for the SBP and 3.6 mmHg for the DBP in Tanzania; 6.4 mmHg for the SBP and 3.8 mmHg for the DBP in Bangladesh. OptiBPTM demonstrated accuracy against ISO standards in study populations, including pregnant populations, except in Bangladesh for SBP (criterion 2). Further research is needed to improve performance across different populations and integration within health systems.

Transitioning to Digital Systems: The Role of World Health Organization's Digital Adaptation Kits in Operationalizing Recommendations and Interoperability Standards.

INTRODUCTION: The transition from paper to digital systems requires quality assurance of the underlying content and application of data standards for interoperability. The World Health Organization (WHO) developed digital adaptation kits (DAKs) as an operational and software-neutral mechanism to translate WHO guidelines into a standardized format that can be more easily incorporated into digital systems. METHODS: WHO convened health program area and digital leads, reviewed existing approaches for requirements gathering, mapped to established standards, and incorporated research findings to define DAK components. RESULTS: For each health domain area, the DAKs distill WHO guidelines to specify the health interventions, personas, user scenarios, business process workflows, core data elements mapped to terminology codes, decision-support logic, program indicators, and functional and nonfunctional requirements. DISCUSSION: DAKs aim to catalyze quality of care and facilitate data use and interoperability as part of WHO's vision of SMART (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) guidelines. Efforts will be needed to strengthen a collaborative approach for the uptake of DAKs within the local digital ecosystem and national health policies.

Integration of new digital antenatal care tools using the WHO SMART guideline approach: Experiences from Rwanda and Zambia.

OBJECTIVES: Digital tools for decision-support and health records can address the protracted process of guideline adoption at local levels and accelerate countries' implementation of new health policies and programmes. World Health Organization (WHO) launched the SMART Guidelines approach to support the uptake of clinical, public health, and data recommendations within digital systems. SMART guidelines are a package of tools that include Digital Adaptation Kits (DAKs), which distill WHO guidelines into a format that facilitates translation into digital systems. SMART Guidelines also include reference software applications known as digital modules. METHODS: This paper details the structured process to inform the adaptation of the WHO antenatal care (ANC) digital module to align with country-specific ANC packages for Zambia and Rwanda using the DAK. Digital landscape assessments were conducted to determine potential integrations between the ANC digital module and existing systems. A multi-stakeholder team consisting of Ministry of Health technical officers representing maternal health, HIV, digital health, and monitoring and evaluation at district and national levels was assembled to review existing guidelines to adapt the DAK. RESULTS: The landscape analysis resulted in considerations for integrating the ANC module into the broader digital ecosystems of both countries. Adaptations to the DAK included adding national services not reflected in the generic DAK and modification of decision support logic and indicators. Over 80% of the generic DAK content was consistent with processes for both countries. The adapted DAK will inform the customization of country-specific ANC digital modules. CONCLUSION: Both countries found that coordination between maternal and digital health leads was critical to ensuring requirements were accurately reflected within the ANC digital module. Additionally, DAKs provided a structured process for gathering requirements, reviewing and addressing gaps within existing systems, and aligning clinical content.

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers.

BACKGROUND: The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers. METHODS: We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual. FINDINGS: From 7076 hits, we included 80 papers (1994-2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings. CONCLUSION: Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

Implementing antenatal care recommendations, South Africa.

Despite progress in reduction in maternal deaths in South Africa, deaths due to complications of hypertension in pregnancy remain high at 26 deaths per 100 000 live births in 2016. The South African health ministry modified its existing four-visit antenatal care model to align with the World Health Organization's (WHO) 2016 recommendations for the number and content of antenatal care contacts. Implementation of the eight-contact antenatal care recommendations began in April 2017, after adaptation to the national context and nationwide trainings. In this article, we describe the stages of implementation and the monitoring of key indicators. We share lessons, particularly from the important early stages of nationwide scale-up and an analysis of the early results. We analysed samples of maternity case records in four catchment areas in the first year of the updated care model. The mean number of antenatal care contacts among five monthly samples of 200 women increased steadily from 4.76 (standard deviation, SD: 2.0) in March 2017 to 5.90 (SD: 2.3) in February 2018. The proportion of women with hypertension detected who received appropriate action (provision of medical treatment or referral) also increased from 83.3% (20/24) to 100.0% (35/35) over the same period. South Africa's experiences with implementation of the updated antenatal care package shows that commitment from all stakeholders is essential for success. Training and readiness are key to identifying and managing women with complications and developing an efficient antenatal care system accessible to all women.

En dépit des progrès observés dans la diminution des décès maternels en Afrique du Sud, les complications causées par l'hypertension durant la grossesse entraînent encore des pertes élevées, à savoir 26 sur 100 000 naissances en 2016. Le ministère de la Santé sud-africain a modifié son modèle de soins prénatals en quatre visites afin de s'aligner sur les recommandations 2016 de l'Organisation mondiale de la Santé (OMS) relatives au nombre et au type de contacts de soins prénatals. La mise en œuvre des recommandations de soins prénatals prévoyant au moins huit contacts a débuté en avril 2017, après adaptation au contexte du pays et formation à l'échelle nationale. Dans cet article, nous décrivons chaque étape de cette mise en œuvre et la surveillance des principaux indicateurs. Nous partageons les enseignements tirés, en particulier lors des premières étapes cruciales d'intensification au niveau national et d'analyse des résultats initiaux. Nous avons étudié des échantillons de dossiers de maternité dans quatre circonscriptions au cours de la première année d'instauration du nouveau modèle de soins. Le nombre moyen de contacts de soins prénatals sur cinq échantillons mensuels de 200 femmes a augmenté de manière stable, passant de 4,76 (écart type: 2,0) en mars 2017 à 5,90 (écart type: 2,3) en février 2018. Le pourcentage de femmes chez qui une hypertension a été détectée et qui ont bénéficié d'une prise en charge adéquate (traitement médical ou renvoi vers un spécialiste) a également augmenté, de 83,3% (20/24) à 100,0% (35/35) sur la même période. L'expérience de l'Afrique du Sud dans la mise en œuvre du nouveau modèle de soins prénatals montre qu'un engagement de la part de tous les intervenants est essentiel à la réussite de l'initiative. La formation et la préparation sont indispensables pour identifier et prendre en charge les femmes présentant des complications, mais aussi pour développer un système de soins prénatals efficace et accessible à toutes.

A pesar de los progresos realizados en cuanto a la reducción de las muertes maternas en Sudáfrica, las muertes por complicaciones debido a la hipertensión durante el embarazo siguen siendo elevadas, con 26 muertes por cada 100.000 nacidos vivos en 2016. El Ministerio de Salud de Sudáfrica modificó su actual modelo de atención prenatal de cuatro visitas para ajustarlo a las recomendaciones de la Organización Mundial de la Salud (OMS) para 2016 en cuanto al número y el contenido de los contactos de atención prenatal. La aplicación de las recomendaciones de atención prenatal de ocho visitas comenzó en abril de 2017, tras su adaptación al contexto nacional y la formación a nivel nacional. En el presente artículo se describen las etapas de aplicación y el seguimiento de los indicadores clave. Compartimos las lecciones, en particular, las importantes etapas iniciales de la ampliación a escala nacional y un análisis de los primeros resultados. Analizamos muestras de registros de casos de maternidad en cuatro zonas de captación en el primer año del modelo de atención actualizado. El número medio de contactos de atención prenatal entre cinco muestras mensuales de 200 mujeres aumentó de forma constante de 4,76 (desviación estándar, SD: 2,0) en marzo de 2017 a 5,90 (SD: 2,3) en febrero de 2018. La proporción de mujeres con hipertensión detectada que recibieron medidas adecuadas (suministro de tratamiento médico o remisión) también aumentó del 83,3% (20/24) al 100,0% (35/35) en el mismo período. Las experiencias en Sudáfrica en cuanto a la aplicación del conjunto de medidas actualizadas de atención prenatal demuestran que el compromiso de todos los interesados es esencial para el éxito. La formación y la preparación son fundamentales para identificar y tratar a las mujeres con complicaciones, así como para desarrollar un sistema eficiente de atención prenatal accesible a todas las mujeres.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews.

BACKGROUND: Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health. OBJECTIVE: To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC. METHODS: Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews. RESULTS: In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans. CONCLUSIONS: While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

Correction: Building a Digital Tool for the Adoption of the World Health Organization's Antenatal Care Recommendations: Methodological Intersection of Evidence, Clinical Logic, and Digital Technology.

[This corrects the article DOI: 10.2196/16355.].

Building a Digital Tool for the Adoption of the World Health Organization's Antenatal Care Recommendations: Methodological Intersection of Evidence, Clinical Logic, and Digital Technology.

BACKGROUND: One of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as "a document containing recommendations for clinical practice or public health policy." Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery. OBJECTIVE: The objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module. METHODS: The WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module's creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms. RESULTS: The first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman's health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows. CONCLUSIONS: This is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module's implementation will inform the WHO's ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.

Measurement of maternal functioning during pregnancy and postpartum: findings from the cross-sectional WHO pilot study in Jamaica, Kenya, and Malawi.

BACKGROUND: The World Health Organization's definition of maternal morbidity refers to "a negative impact on the woman's wellbeing and/or functioning". Many studies have documented the, mostly negative, effects of maternal ill-health on functioning. Although conceptually important, measurement of functioning remains underdeveloped, and the best way to measure functioning in pregnant and postpartum populations is unknown. METHODS: A cross-sectional study among women presenting for antenatal (N = 750) and postpartum (N = 740) care in Jamaica, Kenya and Malawi took place in 2015-2016. Functioning was measured through the World Health Organization Disability Assessment Schedule (WHODAS-12). Data on health conditions and socio-demographic characteristics were collected through structured interview, medical record review, and clinical examination. This paper presents descriptive data on the distribution of functioning status among pregnant and postpartum women and examines the relationship between functioning and health conditions. RESULTS: Women attending antenatal care had a lower level of functioning than those attending postpartum care. Women with a health condition or associated demographic risk factor were more likely to have a lower level of functioning than those with no health condition. However, the absolute difference in functioning scores typically remained modest. CONCLUSIONS: Functioning is an important concept which integrates a woman-centered approach to examining how a health condition affects her life, and ultimately her return to functioning after delivery. However, the WHODAS-12 may not be the optimal tool for use in this population and additional components to capture pregnancy-specific issues may be needed. Challenges remain in how to integrate functioning outcomes into routine maternal healthcare at-scale and across diverse settings.

Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries.

BACKGROUND: Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner. METHODS: The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic. RESULTS: A total of 22 stakeholders - comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers - from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components - a baseline assessment tool with spreadsheets for data entry and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components' use. CONCLUSIONS: The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

Incidence of maternal peripartum infection: A systematic review and meta-analysis.

BACKGROUND: Infection is an important, preventable cause of maternal morbidity, and pregnancy-related sepsis accounts for 11% of maternal deaths. However, frequency of maternal infection is poorly described, and, to our knowledge, it remains the one major cause of maternal mortality without a systematic review of incidence. Our objective was to estimate the average global incidence of maternal peripartum infection. METHODS AND FINDINGS: We searched Medline, EMBASE, Global Health, and five other databases from January 2005 to June 2016 (PROSPERO: CRD42017074591). Specific outcomes comprised chorioamnionitis in labour, puerperal endometritis, wound infection following cesarean section or perineal trauma, and sepsis occurring from onset of labour until 42 days postpartum. We assessed studies irrespective of language or study design. We excluded conference abstracts, studies of high-risk women, and data collected before 1990. Three reviewers independently selected studies, extracted data, and appraised quality. Quality criteria for incidence/prevalence studies were adapted from the Joanna Briggs Institute. We used random-effects models to obtain weighted pooled estimates of incidence risk for each outcome and metaregression to identify study-level characteristics affecting incidence. From 31,528 potentially relevant articles, we included 111 studies of infection in women in labour or postpartum from 46 countries. Four studies were randomised controlled trials, two were before-after intervention studies, and the remainder were observational cohort or cross-sectional studies. The pooled incidence in high-quality studies was 3.9% (95% Confidence Interval [CI] 1.8%-6.8%) for chorioamnionitis, 1.6% (95% CI 0.9%-2.5%) for endometritis, 1.2% (95% CI 1.0%-1.5%) for wound infection, 0.05% (95% CI 0.03%-0.07%) for sepsis, and 1.1% (95% CI 0.3%-2.4%) for maternal peripartum infection. 19% of studies met all quality criteria. There were few data from developing countries and marked heterogeneity in study designs and infection definitions, limiting the interpretation of these estimates as measures of global infection incidence. A limitation of this review is the inclusion of studies that were facility-based or restricted to low-risk groups of women. CONCLUSIONS: In this study, we observed pooled infection estimates of almost 4% in labour and between 1%-2% of each infection outcome postpartum. This indicates maternal peripartum infection is an important complication of childbirth and that preventive efforts should be increased in light of antimicrobial resistance. Incidence risk appears lower than modelled global estimates, although differences in definitions limit comparability. Better-quality research, using standard definitions, is required to improve comparability between study settings and to demonstrate the influence of risk factors and protective interventions.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 1 - Using qualitative evidence synthesis to inform guideline scope and develop qualitative findings statements.

BACKGROUND: WHO has recognised the need to ensure that guideline processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. Along with decision-making criteria that require findings from effectiveness reviews, WHO is increasingly using evidence derived from qualitative evidence syntheses (QES) to inform the values, acceptability, equity and feasibility implications of its recommendations. This is the first in a series of three papers examining the use of QES in developing clinical and health systems guidelines. METHODS: WHO convened a group of methodologists involved in developing recent (2010-2018) guidelines that were informed by QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Our aim in this paper is to (1) describe and discuss how the findings of QES can inform the scope of a guideline and (2) develop findings for key guideline decision-making criteria. RESULTS: QES resulted in the addition of new outcomes that are directly relevant to service users, a stronger evidence base for decisions about how much effective interventions and related outcomes are valued by stakeholders in a range of contexts, and a more complete database of summary evidence for guideline panels to consider, linked to decisions about values, acceptability, feasibility and equity. CONCLUSIONS: Rigorously conducted QES can be a powerful means of improving the relevance of guidelines, and of ensuring that the concerns of stakeholders, at all levels of the healthcare system and from a wide range of settings, are taken into account at all stages of the process.

Qualitative Evidence Synthesis (QES) for Guidelines: Paper 3 - Using qualitative evidence syntheses to develop implementation considerations and inform implementation processes.

BACKGROUND: This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations. METHODS: WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines. RESULTS: For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts. CONCLUSIONS: QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.